welfare state matters: a typological multilevel analysis of wealthy countries
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Welfare State Matters: A Typological Multilevel Analysis of Wealthy Countries. Hae-Joo Chung, RPh, MSc Department of Health Policy and Management, The Johns Hopkins School of Public Health. Summary of Today’s Presentation. - PowerPoint PPT PresentationTRANSCRIPT
Welfare State Matters: Welfare State Matters: A Typological Multilevel A Typological Multilevel
Analysis of Wealthy Analysis of Wealthy CountriesCountries
Hae-Joo Chung, RPh, MScDepartment of Health Policy and Management,
The Johns Hopkins School of Public Health
Summary of Today’s Summary of Today’s PresentationPresentation
To assess the relevance of ‘welfare-state typologies’ to public health research,
And to extend the social epidemiology based on the ‘income inequality paradigm’
We analyzed 3 level conditional hierarchical models of the population health data from 19 wealthy countries of the last 35 years
As a result, the regime-type effects, especially social democratic regime type had a strong explanatory power
And we could see that the social democracies had maintained better population health status for the last 35 years
Welfare State TypologiesWelfare State Typologies
Welfare-state typology has been proved to be a useful explanatory device for the emergence of welfare states, including national health policies
Three (Esping-Andersen) or four (Huber & Stephens) regime-type clusters based on qualitatively different arrangements between state, market and family “Liberal” Welfare States “Wage Earner” Welfare States “Conservative-Corporatist” Welfare States “Social Democratic” Welfare States
Esping-Andersen G. (1990) The Three Worlds of Welfare Capitalism
Huber E and Stephens JD (2001) Development and Crisis of the Welfare State
More generous
The Field of Political · Welfare The Field of Political · Welfare State Determinants of HealthState Determinants of Health
The “Relative Income Hypothesis” and “Political and Welfare-state determinants of Health”, two possible mechanisms
Welfare state variables are used to determine the structural mechanism through which economic inequality affects population health status
Studies suggest that welfare state variables (e.g., access to health care) could be important predictors of population health outcomes
However, only one study included a comprehensive number of political variables that adjust for economic determinants
Coburn, 2000; Conley & Springer, 2001; Navarro & Shi, 2001; Macinko, Starfield, & Shi, 2003; Macinko, Shi, & Starfield, 2004; Muntaner, Lynch, Hillemeier, Lee, David, Benach et al., 2002
Methodological Individualism in Methodological Individualism in Comparative Health Policy Comparative Health Policy AnalysesAnalyses
Assumes covariances Among the observations within
each country Not between/ among countries
Outcomes of a country are explained by explanatory variables of that country
Countries are independent from each other
Country A
Year Obs1990 a 1991 b 1992 c
.
.
.
Country A
Year Obs1990 a 1991 b 1992 c
.
.
.
Country B
Year Obs1990 a´ 1991 b´ 1992 c´
.
.
.
Country B
Year Obs1990 a´ 1991 b´ 1992 c´
.
.
.
Country-level fixed-effects Country-level fixed-effects models using panel datasetsmodels using panel datasets
These are dependentThese are dependent
These are independentThese are independent
AimAim
To develop a more realistic model for comparative health policy analyses than widely used country-level fixed effects model
To examine the change in selected population health indicators in advanced capitalist countries in the last 35 years (1965-1994), especially before and after the neo-liberal welfare reform
HypothesisHypothesis
Generosity of the Welfare-state System
Better Health
Worse Health
Generosity of the Welfare-state System
[ A “Linear” Distribution ] [ A Distribution as “Clusters” ]
Social Social DemocraciesDemocracies
ChristianChristianDemocraciesDemocracies
WageWageEarnerEarner
LiberalLiberal
Countries and CategorizationsCountries and Categorizations
19 wealthy countries, 1960 - 1994 (35 years) Social Democratic
Denmark Finland Norway Sweden
Christian Democratic Austria Belgium France Italy Luxembourg* Netherlands Switzerland (West) Germany
Wage Earner Australia Japan* New Zealand
Liberal Canada Ireland The United Kingdom The United States of America
Outcome Variables and Data Outcome Variables and Data SourcesSources
Outcome variables The infant mortality rate (IMR) The Low birth weight rate (LBW)
Data source The OECD Health Data 2000
k2=0k2=0 k2=1k2=1
Three-level Conditional Three-level Conditional Hierarchical Mixed-effects Hierarchical Mixed-effects Models: A DiagramModels: A Diagram
Level k: Welfare state regimes k1=0, 1, 2, 3, or
k2=0, 1 Fixed effects
Level j: Countries j=1, 2, 3, …, 19 Random effects
Level i: Years i=0, 1, 2, …, 34 Random effects
k1=0k1=0 k1=1k1=1 k1=2k1=2 k1=3k1=3
…
…
…
Statistical AnalysesStatistical Analyses
Two outcomes (IMR and LBW) were analyzed separately SAS version 8.2 was used to obtain the estimates through the REML method
Type of the ModelType of the Model No. of Welfare No. of Welfare State CategoriesState Categories
Years analyzedYears analyzed
3-level conditional hierarchical mixed-effects model
4 (SD, CD, WE, L)
1960-1994 (35 years)
3-level conditional hierarchical mixed-effects model
2(SD, Others)
1960-1994 (35 years)
3-level conditional hierarchical mixed-effects model
2(SD, Others)
1960-1969, 1970-1979, 1980-1989, 1990-1994, separately
11
22
33
Values for Fixed Intercepts for Values for Fixed Intercepts for IMR and LBW in the 4 Regime IMR and LBW in the 4 Regime TypesTypes
10.5
15.6
13.0
15.1
4.85.5 5.8 6.1
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
IMR (n=665) LBW (n=475)
Social Democratic
Christian Democratic
Wage Earner
Liberal
All intercepts p<0.001
Results from the Analysis with Results from the Analysis with 4 Welfare State Regime Types4 Welfare State Regime Types
Results from the Analysis with Results from the Analysis with 2 Welfare State Groups, 1960-2 Welfare State Groups, 1960-19941994
Variance components for ‘year’ and ‘country’-level random-effects are highly significant
All fixed-effects intercepts for ‘welfare state regime types’ are highly significant
F-test is significant for both outcomes
Change in Excess Infant Change in Excess Infant Mortality Rate and Excess Low Mortality Rate and Excess Low Birth Weight Rate:Birth Weight Rate:Social Democracies vs OthersSocial Democracies vs Others
0.27
0.220.25
0.26
0.43 0.40
0.28
0.21
0.00
0.10
0.20
0.30
0.40
0.50
1960-1969 1970-1979 1980-1989 1990-1994
IMR
IMRIMR
LBWLBW
(μ(μ00 -
μ -
μ11) )
μμ00
Variance ComponentsVariance Components
44.4
5.3
8.7
9.8
22.3
22.0
16.4
2.9
4.9
2.5
1.5
1.5
0.6
0.7
0.6
0%
20%
40%
60%
80%
100%
Overall(1960-1994)
1960-1969
1970-1979
1980-1989
1990-1994
Error Country Welfare State
0.23
0.53
0.48
0.06
0.53
0.69
0.19
0.51
0.56
0.11
0.49
0.60
0.06
0.68
0.66
0%
20%
40%
60%
80%
100%
Overall(1960-1994)
1960-1969
1970-1979
1980-1989
1990-1994
Error Country Welfare State
IMRIMR LBWLBW
SummarySummary
Our results provide a more appropriate account of country and regime effects than the usual pooled regression analysis used in comparative health policy analysis.
Our results confirm that countries as clusters or groups share certain characteristics pertaining to them, as opposed to countries as individuals
The Social Democratic regime was significantly different from other countries as a whole
During the era of welfare state retrenchment, the difference in the low birth weight rate between social democracies and other countries was magnified
These Findings Could Be Due These Findings Could Be Due to,to,
The development of domestic welfare state social policies universal access to health care higher female employment in the labor market higher unemployment compensation subsidies to single mothers and divorced women active labour-market intervention to ensure full employment,
especially among women Or any supra-national structure: EU, NAFTA, etc. Or the geographical proximity (policy diffusion)
Implications of the Different Implications of the Different Pattern between IMR and LBWPattern between IMR and LBW
The Social Democratic countries managed to maintain a healthier social environment, including smaller economic inequality, even after 1979, the era of welfare state retrenchment
This finding is also consistent with Huber & Stephens’ (2001) finding: in the changed environment of the 1980s, “the active, service-oriented Social Democratic welfare states were in a stronger position than the passive, transfer-oriented Christian Democratic welfare states” (p.321)
This statement also applies to the Liberal and Wage Earner welfare states that had started “ideologically driven cuts” (p.320) in the state welfare funding much earlier in time
Contributions and LimitationsContributions and Limitations
This study shows that population-level health indicators, such as infant mortality rate and low birth weight, have components of variance at the welfare state type supranational level (15% to 50% or more of the total variability)
This study combined a longitudinal approach with a multi-level modeling approach to get stronger inferences
We do not know for sure if the observed distinctive characteristics in population health are because of policy/ political differences or just reflections of geographical difference. (i.e., All Social Democratic Countries are located in Nothern Europe, whereas all Liberal countries are outside Europe, except the UK, which is a island)
We do not know what aspect of welfare state regimes resulted in the difference in population health levels
CONTRIBUTIONSCONTRIBUTIONS LIMITATIONSLIMITATIONS
Conclusion and Future Conclusion and Future DirectionsDirections
Welfare state policies affecting maternal and child health indicators begin at a supranational level
Comparative health policy studies should not consider countries as being independent from one anther
The differences in population health indicators among these countries distribute as distinctive clusters of welfare state regime types
More protective types of welfare state regimes, namely Social Democratic countries as a group, were able to provide a more population health-friendly environment to its citizens in the last 35 years
Future studies should investigate the specific welfare regime features (i.e., by using explanatory variables) that account for welfare regime effects on maternal and child health and other related population health indicators
CONCLUSIONCONCLUSION FUTURE DIRECTIONSFUTURE DIRECTIONS
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